The socioeconomic gradient of alcohol use
Authors: Charles D H Parry, Gianna Gayle Herrera Amul
Journal: The Lancet Global Health (2022)

In The Lancet Global Health, Yuanwei Xu and colleagues1Xu Y Geldsetzer P Manne-Goehler J et al.The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries.Lancet Glob Health. 2022; 10: e1268-e1280Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar make a useful contribution to the alcohol epidemiology field by using data from 336 287 adult participants (aged ≥15 years) on current and heavy episodic drinking (HED) from 55 low-income and middle-income countries (LMICs). The focus on HED is particularly important given the effect of HED on health and social outcomes.2Rehm J How should prevalence of alcohol use disorders be assessed globally?.Int J Methods Psychiatr Res. 2016; 25: 79-85Crossref PubMed Scopus (30) Google Scholar Previous research on the socioeconomic gradient of alcohol use has centred on high-income countries and research in LMICs was limited to single countries or subnational studies. The by Xu and colleagues found that the prevalence of drinking increased with country income group and with individuals’ socioeconomic status within each country income group. Among males, HED was highest in lower-middle-income countries whereas among females HED drinking was highest in low-income countries. The study points to the need for more nuanced approaches to interventions aimed at addressing HED in LMICs. The business model for large alcohol producers in countries in Africa, Asia, and Latin America depends on a substantial proportion of consumers drinking to intoxication, especially at weekends. As Xu and colleagues1Xu Y Geldsetzer P Manne-Goehler J et al.The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries.Lancet Glob Health. 2022; 10: e1268-e1280Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar point out, people in such contexts engaging in HED are often from lower socioeconomic groups. Research has found that the drivers of this behaviour include distal factors such as lower prices, aggressive marketing, availability of alcohol often through unregulated outlets, poor government enforcement of regulations or even an absence of regulations, and proximal factors such as peer pressure, a scarcity of recreational opportunities, and poverty.3Room R Carlini-Cotrim B Gureje O et al.Alcohol and Developing Societies: a Public Health Perspective. Finnish Foundation of Alcohol Studies in collaboration with the World Health Organisation, Helsinki2002Google Scholar Although there are gaps in the research base informing the efficacy of evidence-based interventions to address HED in the LMICs,4Siegfried N Parry C Do alcohol control policies work? An umbrella review and quality assessment of systematic reviews of alcohol control interventions (2006–2017).PLoS One. 2019; 14e0214865Crossref Scopus (28) Google Scholar interventions identified in the WHO SAFER initiative5WHOThe SAFER initiative: a world free from alcohol related harms. World Health Organization, Geneva2018Google Scholar are likely to be effective in addressing problems in LMICs. Cost-effective and feasible SAFER interventions include policies aimed at increasing the price of alcoholic beverages (eg, excise taxes, minimum unit pricing, and discount sales bans); policies aimed at bans or comprehensive restrictions on alcohol advertising, promotion, and sponsorship; and reducing the physical availability of alcohol (eg, restrictions on hours of sale and the density of alcohol outlets).4Siegfried N Parry C Do alcohol control policies work? An umbrella review and quality assessment of systematic reviews of alcohol control interventions (2006–2017).PLoS One. 2019; 14e0214865Crossref Scopus (28) Google Scholar Many of these interventions (eg, minimum unit pricing, controls on discount sales, and outlet density) together with restrictions on billboard advertising and digital alcohol marketing and restrictions on the sale of alcohol in larger containers (eg, larger bottles of beer) are particularly likely to have a positive effect on heavy drinking among drinkers of lower socioeconomic status. Addressing these challenges will not be easy because larger producers of alcohol have for decades seen LMICs as a new market6Herrera Amul GG Alcohol advertising, promotion, and sponsorship: a review of regulatory policies in the Association of Southeast Asian Nations.J Stud Alcohol Drugs. 2020; 81: 697-709Crossref PubMed Scopus (3) Google Scholar and have resisted both national and global efforts to better control alcohol. Industry resistance includes seeking to usurp national alcohol policy formulation7Bakke Ø Endal D Vested interests in addiction research and policy alcohol policies out of context: drinks industry supplanting government role in alcohol policies in sub-Saharan Africa.Addiction. 2010; 105: 22-28Crossref PubMed Scopus (125) Google Scholar and at a global level through using the threat of punitive action because of violations of trade agreements if countries implement alcohol policy reforms such as many of those listed earlier.8Jernigan DH Monteiro M Room R Saxena S Towards a global alcohol policy: alcohol, public health and the role of WHO.Bull World Health Organ. 2000; 78: 491-499PubMed Google Scholar As a result, progress in implementing the 2010 Global Strategy to Reduce Harmful Use of Alcohol9WHOGlobal strategy to reduce the harmful use of alcohol. World Health Organization, Geneva2010Google Scholar has been uneven and there is increasing recognition of the need for increasing support for implementation of the WHO Global Alcohol Action Plan10WHODraft action plan (2022–2030) to effectively implement the global strategy to reduce the harmful use of alcohol as a public health priority. World Health Organization, Geneva2022Google Scholar approved by the World Health Assembly in May, 2022, and more broadly to negotiating an international legal instrument for alcohol control like that exists for tobacco. These steps would be crucial to ensure progress in addressing the harmful use of alcohol and especially in limiting the alcohol industry's efforts to hinder alcohol policy reform at national and global levels. Parallel to taking action to address the harmful use of alcohol in LMICs and elsewhere, it is crucial to strengthen the evidence base with research on what will work to address this socioeconomic gradient in LMICs and the resulting burden of alcohol use and harm in lower socioeconomic status populations. In line with a key research recommendation from an umbrella review of systematic reviews of alcohol control policies,4Siegfried N Parry C Do alcohol control policies work? An umbrella review and quality assessment of systematic reviews of alcohol control interventions (2006–2017).PLoS One. 2019; 14e0214865Crossref Scopus (28) Google Scholar LMICs that implement one or more policies to reduce harmful drinking should consider options for impact assessment. LMICs can start to properly evaluate the impact of such interventions either through time series analyses or through standardised and context-specific metrics to systematically assess the impact of change over time or to implement quasi-experiments with control groups in comparable countries or subregions within a country. Furthermore, in line with the central finding of Xu and colleagues,1Xu Y Geldsetzer P Manne-Goehler J et al.The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries.Lancet Glob Health. 2022; 10: e1268-e1280Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar this evaluation should include sensitivity to not only ensuring that any action taken at both national and global levels is mindful of the extent of harmful drinking and its associated consequences among lower socioeconomic status groups in LMICs, but also assessing whether the action taken has a meaningful impact on such groups. We declare no competing interests. The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countriesThe findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs. Full-Text PDF Open Access